Learn about the utilization review process at LifeWise.
Many services require review before they're provided. Whenever possible, submit a review request before providing the service. This helps us pay claims faster with no unexpected cost to you or the member after the services are provided.
Sometimes a service requires prior authorization. If you don't get a prior authorization, it could result in a payment penalty for you or the member. Note: You can't submit a prior authorization request by phone.
When a service requires pre-service review, there isn't a penalty, but we'll hold the claim and ask for medical records.
Individual Plans use a new code list, prior authorization tool, and online submission tool Identifi (not eviCore) for outpatient rehabilitation services. Sign in for access to Individual Plan tools.
To see if a prior authorization or pre-service review is required, check our
code list or sign in to get member-specific information using the prior authorization tool. Use the
2024 code list for dates of service starting Jan. 5, 2024.
Sign in and submit a request with the member’s ID number using our prior authorization tool.
step-by-step guide on how to use the prior authorization tool.
It takes 1-5 business days for LifeWise to authorize your use of the tool. Signing into our secure site automatically triggers the authentication process and you will receive a confirmation email once access is granted. During the delay, you can fax a prior authorization request.
You can also complete and fax our
request form to 888-613-1497. Be sure to include the needed supporting documentation (see our
Sign in to the online prior authorization tool to get the status of a request. You can search for requests by reference number, requesting provider, or patient name. You can also edit a submitted prior authorization request in the tool.
For more information about our online prior authorization tool, read our
Individual plans use one prior authorization
request form for all services including durable medical equipment (DME) and provider-administered infusion drugs.
For advanced imaging, prior authorization requests must go through Carelon (formerly AIM). Learn more about Carelon Medical Benefits Management.
We require review for procedures or services that could be a health and safety issue for our members. This includes most planned inpatient services, some planned outpatient DME, and many in-office pharmacy services including injectables, IVs, and biologics.
Common services that require prior authorization include, but are not limited to:
For inpatient stays, you can fax the patient’s hospital face sheet to our utilization management team at 888-613-1497 or you can submit an admission and discharge notification. You don’t need to send a hospital census. Submitting a face sheet or notification helps you get your claims paid correctly and on time.
Trying to see if a prescription medication requires prior authorization? Check out Drugs Requiring Approval.
If an emergency prevents you from getting prior authorization, you must notify us within 48 hours following onset of treatment, or as soon as is reasonably possible.
We know situations arise that can make it impossible for you to get prior authorization before treating a patient, or to notify us within 24 hours of admission. In these situations, please contact us before submitting a claim. Follow the recommended practices detailed in the
extenuating circumstances policy so that the claim isn't automatically denied.